And that is: How do you put forth a substantive proposal that doesn’t first require repealing the Patient Protection and Affordable Care Act (ACA)?

The law’s interlocking pieces make it difficult to tinker around the edges. Most notably, it’s difficult to incorporate popular provisions of the law—such as the ban on discriminating against individuals with pre-existing conditions that Republicans say they want to keep, while simultaneously scrapping its more controversial provisions such as the individual mandate to acquire insurance coverage.

Plus, Republicans have been unable to unify behind a single plan to replace the ACA. One of the major conflict points has been whether to limit the tax exclusion that individuals receive for employer-based coverage. Doing so would help pay for subsidies for individuals who currently lack coverage, but many conservatives view the elimination of the exclusion as a verboten tax hike.

Those intra-party tensions were on display Feb. 27 during a forum put on by conservative policy groups at the National Press Club in Washington. The panel featured Sen. Richard Burr, R-N.C., and Reps. Michael Burgess, R-Texas, Tom Price, R-Ga., Phil Roe, R-Tenn., and Steve Scalise, R-La.

Sen. Burr is co-author of the most detailed Republican alternative to ACA. His bill would scrap the individual mandate in favor of a requirement that insurers offer policies to anyone who’s continuously been insured. In addition, it would replace Medicaid with something akin to a state block grant program. The four House members are all medical doctors who have sponsored various bills that would repeal and replace the ACA.

Rep. Roe indicated that people are constantly questioning why Republicans don’t simply “tweak” the federal healthcare law to make it more appealing. “You cannot fix this bill,” Rep. Roe said. “It’s impossible to do.”

Sen. Burr reiterated the predicament Republicans face in seeking to dismantle the ACA and replace it with something less prescriptive and more attuned to free-market principles. “It’s not the Humpty Dumpty we knew,” he said of what they might end up with instead. “It’s not the Humpty Dumpty we want.”

There’s a lack of trust among the American public with regard to healthcare issues that makes progress difficult, Rep. Burgess argued, in large part because of the turbulent rollout of the ACA. “It’s hard to build that trust when you’ve got so many potholes in the road ahead,” Rep. Burgess said.

Regarding specifics, the Republican legislators at the forum focused most on three ideas: allowing health insurance products to be sold across state lines; expanding the utilization of health savings accounts; and toughening the rules for filing medical malpractice lawsuits. “You address those, healthcare costs will plummet, I promise you,” Rep. Price said.

Recent polling by the Kaiser Family Foundation underscores the GOP dilemma on healthcare. The ACA remains broadly unpopular, with 49 percent expressing disapproval of the law, while just 35 percent indicate support for it. But when asked whether the law should be fixed or repealed, a solid majority—56 percent—support making improvements to the legislation. Less than a third of respondents advocated repealing the law.

Democrats have largely been in a defensive crouch on the issue ahead of 2014 congressional elections.

But there is some indication that they might be seeking to take a more aggressive tact in defending the healthcare law. “Democrats are now on offense over the Affordable Care Act, gaining the political high ground as benefits kick in and provide the ammunition to put Republicans on their heels over the costs of repeal,” reads a memo issued Feb. 26 by Kelly Ward, executive director of the Democratic Congressional Campaign Committee.

Whether Democrats will sustain that aggressive posture remains to be seen. But in a non-presidential election year, with turnout anticipated to be correspondingly low, both sides will likely be seeking to appeal to their bases. For Republicans, that will likely mean reverting to the simpler campaign slogan of repealing the controversial healthcare law.

This report appeared in Crain’s Modern Healthcare magazine, a Chicago-based sister publication of Tire Business.